CBD Dosing for a Six-Year-Old Child
For a 6-year-old child with drug-resistant epilepsy (specifically Lennox-Gastaut syndrome or Dravet syndrome), CBD (Epidiolex®) should be initiated at 2.5 mg/kg twice daily (5 mg/kg/day total), then increased after one week to a maintenance dose of 5 mg/kg twice daily (10 mg/kg/day total), with potential escalation up to a maximum of 10 mg/kg twice daily (20 mg/kg/day total) if needed for seizure control. 1
FDA-Approved Indications and Dosing
CBD is only FDA-approved for specific pediatric epilepsy syndromes, not for anxiety or other conditions in children. 1
Starting dose:
- Begin at 2.5 mg/kg twice daily (total 5 mg/kg/day) 1
- After one week, increase to maintenance dose of 5 mg/kg twice daily (10 mg/kg/day) 1
Dose escalation if needed:
- May increase to maximum of 10 mg/kg twice daily (20 mg/kg/day) based on clinical response 1
- The 20 mg/kg/day dose showed greater efficacy (37.2% of patients achieved ≥50% seizure reduction) compared to placebo (21.2%) 2
Critical Safety Monitoring Requirements
Hepatotoxicity surveillance is mandatory:
- Check liver enzymes (AST/ALT) before starting CBD 1
- Recheck at 1 month, 3 months, and then periodically 1
- Dose-related transaminase elevations occur in 13% of patients, typically within the first 2 months 1
- No cases of liver injury reported at total daily doses <300 mg/day 1
- One-third of elevations resolve spontaneously; others improve with dose reduction or discontinuation 1
Common adverse effects to monitor:
- Somnolence, decreased appetite, diarrhea, and fatigue occur in 87.9% of CBD-treated patients versus 72.2% on placebo 2
- These effects are dose-dependent and more common at 20 mg/kg/day than 10 mg/kg/day 2
Drug-Drug Interactions
CBD significantly interacts with multiple medications:
- Anti-epileptic drugs (particularly valproate, which increases hepatotoxicity risk) 3
- Acetaminophen 3
- Other CNS depressants 1
- The mechanism involves inhibition of cytochrome P450 enzymes and drug transporters 3
Important Clinical Context
CBD is NOT recommended for anxiety in children:
- No FDA approval exists for pediatric anxiety disorders 1
- Evidence for anxiety treatment is mixed and lacks well-powered randomized controlled trials 4
- For 6-year-olds with anxiety, first-line treatment is cognitive behavioral therapy (CBT), with SSRIs as second-line pharmacotherapy 1
CBD should only be used for epilepsy in this age group:
- Clear evidence supports CBD efficacy only for Lennox-Gastaut syndrome, Dravet syndrome, and tuberous sclerosis complex 5, 4
- Meta-analyses confirm 19.5-19.9 percentage point greater reduction in seizure frequency versus placebo 2
- Treatment withdrawal due to adverse events occurs in 8.9% of CBD patients versus 1.8% on placebo 2
Critical Pitfalls to Avoid
- Do not use unregulated CBD products - only FDA-approved Epidiolex® has consistent dosing and purity 4
- Do not skip liver function monitoring - hepatotoxicity is the most serious dose-related adverse effect 1, 6
- Do not combine with valproate without extreme caution - this combination significantly increases liver injury risk 3
- Do not use for off-label indications in children - evidence is insufficient for conditions other than specific epilepsy syndromes 4